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rr 1 � <br /> PUBLIC HEA:. I SERVICES-ENVIRONMENTAL H. LTH DIVISION <br /> SITE NAME 'p-AC`/ Kq Ru,�E ADDRESS3 i c�:i t c:z] CITY iC�F3C�J <br /> OWNER NAME OWNER PHONE # SSS <br /> CONTRACTOR ���f L'r t�-[�. CONT. PHONE 14 <br /> FIRE PERMIT <br /> REMOVAL X CLOSURE IN PLACE TEMPORARY CLOSURE <br /> INSPECTOR �O (pkc, DATE f 0/51 �q TANK # 3 9 t - G( <br /> R RINSED 01,T) TMETH011 X =RINSE AMOUNT 15� <br /> I <br /> N RINSATE DISPOSAL SITE <br /> S <br /> LEj MANIFEST Cf�04 I SS Z OR OTHER <br /> V VAPORS PURGED LJ ) METHOD (�,� AMOUNT USED JCD <br /> A <br /> P READING AT REMOVAL L.E.L. : 02: 0 <br /> O <br /> R COv2=S <br /> C TANK MATERIAL tlE FIBERGLASS, OTHER) <br /> 0 <br /> N TANK CONDITION (GOOD �OR ) HOLES) np G�c:�o4�g hots 5 <br /> S <br /> T PIPE MATERIAL kE!EE9)l FIBERGLASS, OTHER) FEET <br /> PIPE CONDITION (GOOD, _ , HOLES) <br /> DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> A <br /> N r <br /> K <br /> S EXCAVATION SIZE l3 X 2{ X YDS OF SOIL <br /> A <br /> M DEPTH SOIL TYPE OBSERVATION SAMPLE <br /> L I -z.5' _ r 4 <br /> I p <br /> N E <br /> G <br /> TRENCH DIMENSION X X YDS OF SOIL HI <br /> - I <br /> DEPTH TO G.W. : FT. SAMPLING METHOD <br /> H <br /> 2 a HOURS SINCE DEWATERING: <br /> 0 <br /> OTHER SAMPLE: <br /> LABORATORY: SAMPLERS NAME: <br /> CLOSURE IN PLACE FIXTURE: I VOLUME: <br /> EH 23-0043 (REV 2/23/94) PROVIDE SITE MAP <br />